Form Seh-3 - Request Absence For Personal Illness / Illness In Family printable pdf download

NOTE: Top and bottom portions of this form must be filled out in their entirety and returned to Employee Health Services to insure continuation of salary.

REQUEST ABSENCE FOR

THE SCHOOL DISTRICT OF PHILADELPHIA

EMPLOYEE HEALTH SERVICES - SUITE 134

PERSONAL ILLNESS / ILLNESS IN FAMILY

440 N. BROAD STREET - PHILADELPHIA, PA 19130



A NEW CARD MUST BE SUBMITTED FOR EACH PAYROLL PERIOD --- NOT TO EXCEED 10 DAYS.



FAILURE TO SUBMIT CARDS MAY LEAD TO DISCIPLINARY ACTION.



EMPLOYEES ON LONG-TERM ILLNESS/ILLNESS IN FAMILY MAY NOT LEAVE THE CITY WITHOUT PRIOR APPROVAL FROM EMPLOYEE HEALTH SERVICES.

SECTION I - COMPLETED BY EMPLOYEE



Employee’s Last Name

First Name

M.I.

Employee ID

Date

Home Address

City

State

Zip Code

Home Phone

Work Location (School/Office)

Organization No.

Position Title

Number of Days Absent

From Date ( Month/Day/Year )

To Date ( Month/Day/Year )

Anticipated Date of Return

Signature of Employee

Signature of Principal/Administrator

Date

= = = THIS CARD DOES NOT REPLACE A MEDICAL REPORT FROM YOUR DOCTOR = = =

SEH-3 Part 1 (Rev. 11/11) Comm. Code 61602445418



SECTION II - AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION - ALL INFORMATION WILL BE KEPT CONFIDENTIAL

FOR EMPLOYEE ILLNESS

FOR ILLNESS IN THE FAMILY

I, the undersigned, authorize the release of all information regarding this

illness to the Office of Employee Health Services, for which I am requesting

personal illness absence.

Name of Employee: _________________________________________

Name of Family Member: ____________________________________

Name of Employee: ____________________________________________

Relationship to Employee:____________________________________

Employee I.D.: __________________________

Signature: _________________________________

Date:____________



SECTION III - COMPLETED BY EMPLOYEE’S PHYSICIAN OR FAMILY MEMBER’S PHYSICIAN

Name of Patient:_________________________________________________

Date of Last Visit: _________________________________

I certify that the above patient is / was under my professional care from (date) ____________________________ to ___________________________

The patient’s diagnosis/diagnoses: ____________________________________________________________________________________________

___ Disability From Pregnancy (EDD:___________________________ )

Other:___________________________________________________

= = = FORGERY OF PHYSICIAN’S SIGNATURE IS SUBJECT TO DISCIPLINARY ACTION = = =

Date employee may return to work

Physician’s Name:__________________________________________

Telephone:___________________

(Do not indicate indefinitely)

Address:_________________________________ City________________ State_____ Zip Code___________

____________________________

Signature:__________________________________________

Date: ______________________________

SEH-3 Part 2 (Rev. 11/11) Comm. Code 61602445418

Form Seh-3 - Request Absence For Personal Illness / Illness In Family

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